Smoking among Brazilian adolescents during the COVID-19 pandemic: a cross-sectional study

ABSTRACT BACKGROUND: The social distancing measures during the coronavirus disease 2019 (COVID-19) pandemic resulted in mental suffering among adolescents, leading to risky consumption of psychoactive substances such as tobacco. OBJECTIVE: To analyze the factors associated with tobacco use among adolescents during the COVID-19 social distancing period in Brazil. DESIGN AND SETTING: Cross-sectional study used data from ConVid Adolescentes survey in Brazil. METHODS: Tobacco use was assessed before and during social distancing. The explanatory variables investigated were sex, age, race/skin color, type of school, maternal education, region of residence, adherence to social restriction measures, number of close friends, sleep quality during the pandemic, mood, passive smoking, use of alcoholic beverages during the pandemic, sedentary behavior, and physical activity. A logistic regression model was used for the data analysis. RESULTS: Tobacco use by adolescents did not change during the pandemic (from 2.58% to 2.41%). There was a higher chance of tobacco use among adolescents aged between 16 and 17 years, self-reported black ones, residing in the South and Southeast regions, reported feeling sad and loneliness, had sleeping problems that worsened, were using alcoholic beverages during the pandemic, and were passive smokers at home. Adolescents whose mothers had completed high school or higher, had strict social restrictions, and increased their physical activity during the pandemic had a lower chance of tobacco use. CONCLUSION: Tobacco uses during the COVID-19 pandemic was higher in vulnerable groups, such as black adolescents and those with mental suffering.

and individuals with incomplete secondary education. The increase in cigarette consumption among Brazilian adults was associated with worse sleep quality, feeling sad or depressed, anxiety, feeling isolated from family members, having no income, and worse health status. 5 A study in Spain showed that smoking during the pandemic was used by adolescents to relieve unpleasant emotions. 16 Among Brazilian adolescents, a study analyzing data from the ConVid Adolescentes Survey showed a decrease in tobacco consumption. 17 However, the factors associated with tobacco consumption during the pandemic have not yet been analyzed.

OBJECTIVE
This study aimed to analyze the factors associated with tobacco use among adolescents during the social distancing period in Brazil during the COVID-19 pandemic.

METHODS
A cross-sectional study that analyzed the database of "ConVid Because sampling by networking is not probabilistic, to obtain a representative sample of the population according to geographic and sociodemographic characteristics, weights were calculated using post-stratification procedures. 19 The sample was calibrated using data from the National School Health Survey, 20 and aimed to obtain the same distribution by region of residence, sex, age group (12-15 years; 16-17 years), and type of school (public or private).

Variables
In the present study, tobacco consumption before and during the pandemic was analyzed by asking the following questions: a) Before the pandemic, did you smoke cigarettes? (Yes or No); b) During the pandemic? 1-I did not smoke cigarettes; 2-I am smoking less than I used to; 3-I continued to smoke at the same frequency; 4-I am smoking more than I used to; 5-I stopped smoking but I started smoking again. Adolescents who answered "yes" to the question before the pandemic and options 2, 3, 4 or 5 during the pandemic were considered smokers.

Statistical analyzes
Initially, the prevalence and 95% confidence interval (CI) of cigarette consumption before and during the pandemic were calculated for the total sample according to the explanatory variables.
To verify the possible factors associated with smoking during the pandemic, crude and adjusted odds ratios (ORc and ORa, respectively) by sex, age group, and type of school logistic regression models were used, with a significance level of 5%. were less likely to consume tobacco ( Table 2).

DISCUSSION
The "Convid Adolescentes" survey evaluated the changes in the lifestyle of Brazilian adolescents during social distancing of the COVID-19 pandemic. This study shows that tobacco consumption did not change during the pandemic. Higher consumption     was associated with older adolescents, black race/color of the skin, residing in the South and Southeast regions, who reported feelings of sadness and loneliness, whose sleeping problems worsened, who consumed alcoholic beverages during the pandemic, and who reported passive smoking. Tobacco consumption was lower among adolescents whose mothers had higher educational levels, who studied in private schools, who adopted stricter social distancing measures during the pandemic, and who increased their physical activity during the pandemic. This study demonstrated the stability of smoking habits among adolescents during the pandemic. Previous studies found the same pattern. 16,21 On one hand, the stress and anxiety produced by the period of social isolation can be considered triggers for unhealthy behaviors and some adolescents could use smoking as a coping mechanism for these adverse feelings. 22 On the other hand, the decrease in income and the closure of establishments aimed at social interaction, such as bars and restaurants, may have reduced adolescents' access to cigarettes. 23,24 Thus, more studies are needed to better understand the reasons for the stability of this prevalence.
Notably, the prevalence in the current study was lower than that in Spain 16 and that in the data from the National Survey of School Health (Pesquisa Nacional de Saúde do Escolar [PeNSE]) 2019, which showed that tobacco consumption in the last 30 days was 6.8% (6.3-7.3) for students aged 13-17 years. 25 The results showed a higher prevalence of tobacco consumption in older adolescents, which is in line with other studies. 16 In PeNSE 2019, for example, it was found that adolescents aged 16-17 years consume more tobacco than those aged between 13-15 years. 25 Adolescents who reported feelings of sadness, loneliness, and worsened sleep problems during the pandemic had higher tobacco consumption. Studies carried out during the pandemic have suggested that situations of social distancing can have negative consequences on psychological and mental health. [26][27][28][29] Therefore, some adolescents may have been involved with substance use as a way to deal with psychological discomfort and negative feelings related to the COVID-19 situation. 27,28,30,31 The increase in tobacco consumption in some groups may be a way to relieve negative emotions related to COVID-19, deal with boredom, and overcome the lack of social relationships. 27,28,30,32,33 Lower tobacco consumption was observed among children of more educated mothers, which was also observed in a study from Spain for adolescents whose parents had a university education. 16 The COVID-19 pandemic has led to social restrictions, and adolescents spent more time with their parents at home. Higher maternal education may be related to greater access to information, not only on the risks of tobacco but also on the possible respiratory aggravations that COVID-19 can generate in smokers. 16,30 Thus, a family attitude of disapproval of tobacco consumption by adolescents at home may have contributed to this reduction.
Smoking was higher among Black adolescents, which may reflect their greater vulnerability. In Brazil, race/skin color is associated with lower income and may also be associated with parents with less education, which would lead to less access to information. 16 Passive smoking had the strongest association among adolescents. This finding was also identified in a previous study with data from PeNSE 2015, 14 among other studies. 34 Passive smoking at home denotes the marked influence of family members and close people, and which are highlighted by the theory of social learning. 35 Thus, adolescents frequently exposed to passive smoking naturalize the practice and end up adopting it.
The association between alcohol consumption and a greater chance of smoking during the pandemic may be explained by the fact that both habits are seen as a source of social acceptance, 36 in addition to being risky behaviors based on the same vulnerabilities, such as feelings of sadness and isolation. 37 Furthermore, a previous study showed that the consumption of alcoholic beverages increases the desire to smoke in people who already consume cigarettes. 38 In line with this study, data from PeNSE 2019 show that the prevalence of tobacco use in the last 30 days was also higher in the South region of the country (8.0%; 95% CI: 7.1-8.7) and Southeast (7.6%; 95% CI: 6.4-8.7), compared to the North (4.7%; 95% CI: 4.3-5.2). 25 Previous studies have suggested that the tobacco control measures implemented in the country were critical in the decline of smoking prevalence among adults 40 25 Among the limitations of the present study, it is worth mentioning that a non-random sample was selected via the Web, which may not have reached all social segments, although post-stratification weights were applied. The data obtained were based on reports by adolescents, which may have led to information bias. Furthermore, this is a cross-sectional study, which does not allow the establishment of a cause-effect relationship between the associations observed.

CONCLUSION
The results suggest that the COVID-19 pandemic has affected the social lives of young people. Although there was no change in tobacco consumption, it is necessary to remain alert, especially in older black adolescents who are subjected to passive smoking at home, have mental suffering, and have less-educated parents.